Form Alternate Dispute Alternate Dispute FCC Form 5628

OMB Control No. 3060-XXXX

Estimated Time Per Response: 3 hrs.

F ederal Communications Commission

Office of Workplace Diversity

ADR Intake Form

Case. No.:

1. EMPLOYEE NAME (Last, First, Middle Initial)			2. MEDIATION NUMBER (OFFICE USE ONLY)
3a. HOME PHONE NO.	3b. WORK PHONE NO.	3c. MOBILE PHONE NO.	3d. PRIMARY EMAIL		3e. SECONDARY EMAIL
4. PREFERRED METHOD OF COMMUNICATION Check if You Only Wish to be Contacted About This Issue at Home. Best Times To Call:			5. ADDRESS OF YOUR CURRENT POSITION
6a. ARE YOU BEING REPRESENTED? a. Yes (Complete 6b and 7) b. No 6b. IF YES, NAME OF REPRESENTATIVE Best Times to Call:			7. ADDRESS, PHONE NUMBER AND EMAIL OF REPRESENTATIVE
8a. ARE YOU CURRENTLY A FEDERAL EMPLOYEE? a. Yes (Complete 8b and 8c) b. No 8b. Dates Available for Intake Interview			8c. TITLE AND GRADE OF YOUR CURRENT POSITION

9. INDIVIDUAL(S) INVOLVED IN DISPUTE

Name	Position	Bureau	Phone

10. HAVE YOU FILED ANY OF THE FOLLOWING (CHECK ALL THAT APPLY)

Negotiated Grievance Administrative Grievance Unfair Labor Practice Charge

EEO Complaint Harassment Complaint Under EEOC Order No. 560.005, Prevention and Elimination of Harassment in the Workplace

11. BRIEFLY DESCRIBE THE DISPUTE
12. PLEASE DESCRIBE EACH INDIVIDUAL’S INVOLVEMENT IN THE DISPUTE
13. EMPLOYEE SIGNATURE	14. DATE OF THIS REQUEST (Month, Day, Year)

FCC-5628, Effective Date: Month 2018

PRIVACY ACT STATEMENT

Authority: The Administrative Dispute Resolution Act, 5 U.S.C. § 571, requires each Federal agency to adopt policies on ADR use; Civil Justice Reform, Executive Order 12,998, 61 Fed. Reg. 4729 (Feb. 5, 1996), promoting the just and efficient resolution of civil claims; and Equal Employment Opportunity Commission regulations and policies on the use of alternative dispute resolution in addressing workplace conflict, 29 C.F.R. §§ 1614.102(b)(2), 1614.105(f), 1614.108(b), and 1614.603.

Purpose: The principal purpose for collecting this information is to permit the Federal Communications Commission (FCC), through its Office of Workplace Diversity and ADR Program, to assist the parties referenced herein in exploring dispute resolution alternatives to issues raised both within this form and issues that may arise among the parties from the information submitted herein. Additionally, the FCC collects and maintains this information to process, resolve, record and track requests for administrative dispute resolution services, by FCC managers, supervisors and employees. Information collected in connection with a request for alternative dispute resolution services is confidential and may be shared with Agency officials or Agency contractors only when those other individuals need to know the information to make determinations resulting from an alternative dispute resolution request or to assist the ADR Manager in making such a determination.

Routine Uses: The records and information in the records may be used pursuant to the Routine Uses for the system found in the System of Records Notice EEOC/GOVT1, Equal Employment Opportunity (EEO) in the Federal Government Complaint and Appeal Records, 81 Fed. Reg. 81,116 (Nov. 17, 2016).

Effect of Disclosure: The provision of information is voluntary; however, if you do not provide this information, the FCC may not provide you with ADR Program services, and you may not receive important information.

PAPERWORK REDUCTION ACT STATEMENT

We have estimated that each response to this collection of information will take three hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Paperwork Reduction Project (3060-XXXX), Washington, DC 20554. We will also accept your comments via the Internet if your send them to pra@fcc.gov. Please DO NOT SEND COMPLETED REQUESTS TO THIS ADDRESS. Remember - you are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-XXXX.

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